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Background The causes of heart failure (HF) during high-grade atrioventricular block (AVB) are poorly understood. This study assessed the mechanisms of HF in patients with AVB. Methods We studied patients presenting (between 2012 and 2016) with high-grade AVB not related to acute myocardial infarction. Patients with preexisting significant valvular heart disease were excluded. All patients underwent comprehensive echocardiographic evaluation during AVB, before pacemaker implantation. The diagnosis of HF was based on the Framingham criteria. Results A total of 122 patients were included in the study, 50% male, average age 76 ± 13 years. Twenty-eight patients (23%) with AVB presented with HF. Univariate correlates associated with HF were decrease in cardiac output (CO) (odds ratio [OR] 0.68 [95% confidence interval 0.49-0.9] per L/min; P = 0.007), measures of impaired left ventricular (LV) compliance, and increase in diastolic mitral regurgitation (MR) volume (OR 1.04 [1.01-1.07] per cc; P = 0.0016). Ventricular rate during AVB and LV ejection fraction were not significantly associated with the presence of HF. By multivariate nominal logistic analysis, the best model associated with HF included diastolic MR volume (OR 1.04 [1.001-1.09]; P = 0.02), A-wave deceleration time (OR 0.96 [0.94-0.9]; P = 0.001), and CO (OR 0.92 [0.4-1.00]; P = 0.005) (χ2 = 30.6; area under the receiver operating characteristic curve = 0.84; P Conclusions In the setting of high-degree AVB, clinical HF occurrence correlates with impaired LV compliance and diastolic MR volume, but not with heart rate or LV ejection fraction. The cardiac performance of patients with poor LV compliance and high-volume diastolic MR may show maladjustment to slow heart rates, manifesting as low CO and HF.

Parasympathetic dysfunction is associated with increased risk for major adverse cardiovascular events (MACE). However, clinically validated biomarkers that reflect parasympathetic activity are not yet available. We sought to assess the ability of serum cholinesterase activity to predict long term survival in patients undergoing coronary angiography.We prospectively followed 1002 consecutive patients undergoing clinically indicated coronary angiography (acute coronary syndrome or stable angina). We measured blood acetylcholinesterase (AChE) activity using the acetylcholine analog acetylthiocholine. Mortality rates were determined up to 10 years of follow-up. We divided our cohort into 3 groups with low, intermediate and high AChE activity by a Chi-square automatic interaction detection method (CHAID).Patients with lower than cutoff levels of AChE (300 nmol/min/ml) had higher mortality rates over 10 years of follow-up, after adjusting for conventional risk factors, biomarkers, clinical indication, and use of medications (HR = 1.6, 95% CI 1.1-2.5, p = 0.02). Patients with intermediate levels of AChE (300-582 nmol/min/ml) were also at increased risk for death (HR = 1.4, 95% CI 1.1-1.9, p = 0.02). AChE was inversely correlated with C-reactive protein, troponin I, fibrinogen and neutrophil/lymphocyte ratio levels.Patients presenting for coronary angiography with low levels of serum AChE activity are at increased risk for death during long term follow-up.

We aimed to validate a new scoring system based on extent of cardiac damage for risk stratification in patients undergoing transcatheter aortic valve replacement (TAVR) in a real-world cohort and to examine the addition of baseline albumin in risk assessment.We investigated 2608 patients undergoing TAVR. Subjects were divided into five groups based on their echocardiography findings. Patients were further assessed by incorporating baseline albumin. Multivariable analysis demonstrated that each increase in stage was associated with significant increased risk of 1-year mortality (HR 1.37, 95%CI 1.23-1.54, p .001). Among patients at increased stage (3-4), incorporation of baseline of albumin identified the highest risk group, such that each 1 decrement in albumin levels was associated with more than triple increase in mortality among patients at stage 3 and 4 (HR 2.77, 95% CI 1.48-5.18, p-value = .001).Cardiac damage classification is validated in a real-world cohort of patients undergoing TAVR. Incorporation of low baseline albumin may further identify patients at the highest risk group.We evaluated 2608 patients undergoing transcatheter aortic valve replacement (TAVR) in order to validate a new scoring system dividing patients in to 5 stages (0-4) based on extent of cardiac damage. Patients were further assessed by incorporating baseline albumin. Multivariable analysis demonstrated that each increase in stage was associated with significant increased risk of 1-year mortality. Furthermore, among patients at increased stage (3-4), incorporation of baseline of albumin identified the highest risk group, such that each 1 decrement in albumin levels was associated with more than triple increase in mortality among patients at stage 3 and 4.

Background In contrast to surgical aortic valve replacement, left ventricle (LV) hypertrophy (LVH) had not been clearly associated with mortality following transcatheter aortic valve replacement (TAVR). Methods We performed a retrospective analysis of patients enrolled in the Israeli multicenter TAVR registry for whom preprocedural LV mass index (LVMI) data were available. Patients were divided into categories according to LVMI: normal LVMI and mild, moderate, and severe LVH. Mild LVH was regarded as the reference group. Additionally, LV geometry patterns were examined (concentric and eccentric LVH, and concentric remodeling). Results The cohort consisted of 1,559 patients, 46.5% male, with a mean age of 82.2 (±6.8) years and mean LVMI of 121 (±29) g/m2. Rates of normal LVMI and mild, moderate, and severe LVH were 31% (n = 485), 21% (n = 322), 18% (n = 279), and 30% (n = 475), respectively. Three-year mortality rates for normal LVMI and mild, moderate, and severe LVH were 19.8%, 18.3%, 23.7%, and 24.4%, respectively. Compared to mild LVH, moderate LVH and severe LVH were independently associated with an increased risk for all-cause mortality (hazard ratio [HR] 1.58, 95% CI 1.15-2.18, P = .005; HR 1.46, 95% CI 1.1-1.95, P = .009; respectively). Concentric LVH was independently associated with a decreased risk for mortality compared to normal LV geometry (HR 0.75, 95% CI 0.63-0.89, P = .001). Compared to concentric LVH, eccentric LVH was independently associated with a 33% increased risk for mortality (HR 1.33, 95% CI 1.11-1.60, P = .002). Conclusions Mild concentric LVH confers a protective effect among patients with severe aortic stenosis undergoing TAVR. However, hypertrophy becomes maladaptive, and an increased baseline LVMI, eccentric pattern particularly, may be associated with all-cause mortality in this population.

Transcatheter aortic valve replacement (TAVR), although associated with an increased risk for acute kidney injury (AKI), may also result in improvement in renal function.The aim of this study is to evaluate the magnitude of kidney function improvement (KFI) after TAVR and to assess its significance on long-term mortality.This is a prospective single center study.The study was conducted in cardiology department, interventional unit, in a tertiary hospital.The cohort included 1321 patients who underwent TAVR.Serum creatinine level was measured at baseline, before the procedure, and over the next 7 days or until discharge.Kidney function improvement was defined as the mirror image of AKI, a reduction in pre-procedural to post-procedural minimal creatinine of more than 0.3 mg/dL, or a ratio of post-procedural minimal creatinine to pre-procedural creatinine of less than 0.66, up to 7 days after the procedure. Patients were categorized and compared for clinical endpoints according to post-procedural renal function change into 3 groups: KFI, AKI, or preserved kidney function (PKF). The primary endpoint was long-term all-cause mortality.The incidence of KFI was 5%. In 55 out of 66 patients patients, the improvement in kidney function was minor and of unclear clinical significance. Acute kidney injury occurred in 19.1%. Estimated glomerular filtration rate (eGFR)60 mL/min/1.73 mThe following are the limitations: heterozygous definitions of KFI within different studies and a single center study. Although data were collected prospectively, analysis plan was defined after data collection.Improvement in kidney function following TAVR was not a common phenomenon in our cohort and did not reduce overall mortality rate.L’implantation transcathéter de valvule aortique (ITVA), bien qu’elle soit associée à un risque accru d’insuffisance rénale aiguë (IRA), est susceptible d’améliorer la fonction rénale.Évaluer l’ampleur de l’amélioration de la fonction rénale (AFR) après une ITVA et évaluer son incidence sur le taux de mortalité à long terme.Étude prospective menée dans un seul centre hospitalier.Le service de cardiologie, unité interventionnelle, d’un centre de soins tertiaires.La cohorte était constituée de 1 321 patients ayant subi une ITVA.Le taux de créatinine sérique a été mesuré à l’inclusion, avant l’intervention et pour les 7 jours suivants, ou jusqu’au congé du patient.L’AFR a été définie comme l’image miroir de l’IRA, soit une réduction de plus de 0,3 mg/dl du taux de créatinine après l’intervention par rapport au taux minimum de créatinine mesuré pré-ITVA, ou un rapport entre la créatinine minimale post-ITVA et la créatinine pré-ITVA inférieur à 0,66 jusqu’à 7 jours après l’intervention. Les patients ont été classés en trois groupes et comparés selon des critères cliniques en fonction de la modification de la fonction rénale après l’intervention : un groupe AFR, un groupe IRA et un groupe « fonction rénale préservée » (FRP). Le critère principal était la mortalité toutes causes confondues.L’incidence d’une AFR était de 5 % et elle s’est avérée mineure et d’importance clinique incertaine pour 55 des 66 patients concernés. La proportion de patients atteints d’IRA était de 19,1 %. Après l’analyse multivariée, un débit de filtration glomérulaire estimé (DFGe) inférieur à 60 ml/min/1,73 mManque de consensus autour de la définition d’une amélioration de la fonction rénale dans les différentes études.Étude menée dans un seul centre.Bien que les données aient été recueillies de façon prospective, le plan d’analyse n’a été défini qu’après la collecte des données.L’amélioration de la fonction rénale après l’ITVA n’était pas un phénomène courant dans notre cohorte et n’a pas permis de réduire le taux de mortalité global.

Background Red blood cell distribution width (RDW), which is routinely reported in complete blood counts, is a measure of the variability in size of circulating erythrocytes. RDW is an independent predictor of prognosis in patients with cardiovascular diseases. We evaluated the short- and long-term prognostic value of RDW in a large cohort of transcatheter aortic valve implantation (TAVI) patients. Methods The impact of RDW on outcome was determined prospectively in 1029 consecutive patients with severe aortic stenosis (AS) undergoing transfemoral TAVI. The cohort was divided into 2 groups according to RDW above and below 15.5%. Collected data included patient characteristics, medical background, left ventricle ejection fraction (LVEF), frailty score, Society of Thoracic Surgeons (STS) score, periprocedural laboratory results, and long-term (up to 7.5 years) clinical outcomes. Results The mean age (±SD) was 83.1 ± 6.3 years, mean STS score was 4.2 ± 3.1% and mean estimated LVEF was 55.7 ± 8.4%. Mean pre-TAVI RDW levels were 15.3 ± 3.2%. Patients with RDW ≤ 15.5% ( n = 683) and RDW > 15.5% ( n = 346) had a 1-year mortality rate of 6% and 17%, respectively ( p = 0.001) and a 5-year mortality rate of 20% and 38%, respectively ( p 15.5% was independently associated with all-cause mortality (hazard ratio 1.83, 95% confidence interval 1.44–2.32, p Conclusions Elevated RDW is a strong independent marker and predictor of short- and long-term mortality following TAVI, that might present a relevant future supplement to current preprocedural risk scores. Additional research is needed to clarify the mechanisms responsible for this finding.

Background: Data concerning transcatheter aortic valve replacement (TAVR) in patients with prior mitral surgery is limited and preliminary reports seem encouraging. We sought to describe TA...

Referral of low surgical risk (LSR) patients for transcatheter aortic valve implantation (TAVI) becomes common in multiple tertiary centers, and clinical trial data for this population are not available to date. We performed a retrospective analysis on an Israeli multicenter registry. LSR and intermediate-high surgical risk (I-HSR) were defined by a Society of Thoracic Surgery score of4% and ≥4%, respectively. The cohort included 2336 patients (LSR n = 1198, I-HLR n = 1138). As compared with LSR, patients with I-HSR were older and had significantly higher rates of baseline comorbidities. Although devices success rates (94% vs 96%), paravalvular leak (3.5% vs 5.2%), and permanent pacemaker implantation (17.2 vs 18%) were comparable (p0.05 for all comparisons), the safety outcome at 1 month (12.7% vs 9.8%), procedural mortality (1.9% vs 0.6%), and mortality at 3 years (30.1% vs 16.1%) were higher in patients with I-HSR (p0.05 for all comparisons). In a subanalysis of patients with very LSR, comparable rates of device success and safety outcomes were observed, whereas mortality at 1 to 3 years was lower. In conclusion, although procedural outcomes were comparable between LSR and I-HSR TAVI patients, the rates of short- and long-term mortality, as well as the safety outcome, were lower in LSR patients.

Current risk models have only limited accuracy in predicting transcatheter aortic valve Implantation (TAVI) outcomes and there is a paucity of clinical variables to guide patient management after the procedure. The prognostic impact of elevated left ventricular end-diastolic pressure (LVEDP) in TAVI patients is unknown. The aim of the present study was to evaluate the prognostic value of after-procedural LVEDP in patients who undewent TAVI. Consecutive patients with severe symptomatic aortic stenosis who undewent TAVI were divided into 2 groups according to after-procedural LVEDP above and below or equal 12 mm Hg. Collected data included baseline clinical, laboratory and echocardiographic variables. We evaluated the impact of elevated vs. normal LVEDP on in-hospital outcomes, short- and long-term mortality. Eight hundred forty-five patients were included in the study with complete in-hospital and late mortality data available for all survivors (median follow-up 29.5 months [IQR 16.5 to 48.0]). The mean age (±SD) was 82.3±6.2 years and mean Society of Thoracic Surgery score was 4.0%±3.0%. Patients with LVEDP12 mm Hg (n = 591, 70%) and LVEDP≤12 mm Hg (n = 254, 30%) had a 6-months mortality rate of 6.8% and 2%, respectively (P=0.004) and a 1-year mortality rate of 10.1% vs 4.9%, respectively (p = 0.017). By multivariable analysis, after-procedural LVEDP12 mm Hg was independently associated with all-cause mortality (HR 2.45, 95% CI 1.58 to 3.76, p0.001) during long-term follow-up. In conclusion, elevated after-procedural LVEDP in patients who undewent TAVI is an independent predictor of mortality following TAVI. Further research regarding the use of LVEDP as a tool for after-procedural medical management is warranted.

Background Coronary artery disease (CAD) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend that percutaneous coronary intervention (PCI) of >70% proximal coronary lesions prior to TAVI. The aim of the current study was to evaluate two approaches to CAD diagnosis pre-TAVI. Methods We investigated 2,027 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural CAD assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results (N=831) or mandatory invasive angiography (IA) (N=1,196). Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented. Results Mean age of the study population was 86±4, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (32% vs. 17%, p Conclusions In elderly patients, CTA driven approach for CAD evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome. Funding Acknowledgement Type of funding source: None

Background Cardiac gated computed tomography angiography (CCTA) is the mandatory pre-interventional imaging planning procedure in patients eligible for trans-catheter valve implantation (TAVR). Automated analysis of the cardiac chambers" volumes including the right ventricle (RV), can be obtained from the CCTA and thus contribute to patient selection. Objectives To assess the prognostic implications of increased RV volume using a fast automated volumetric analysis software on preprocedural CCTA data among patients undergoing TAVR. Methods CCTA of patients who underwent TAVR at two medical centers – Stanford University Medical Center (California, USA) and Tel Aviv Medical Center (Israel) – between 2013 and 2016 were analyzed by an automatic four chamber volumetric analysis (4CVA) software, and grouped according to their RV volume index, into those with the largest RV (upper 5th percentile of RV volume index (>120 ml/m2; n = 16) versus those within the 95th percentile lower volumes index (≤120 ml/m2; n = 307). Differences in baseline characteristics between the groups were adjusted for with a propensity score. The risk for one year mortality following the TAVR was compared between the two groups. Results In total 323 patients were included. There were no major differences in background and demographic characteristics between the study groups. A significantly higher 1-year mortality rate was found for patients with large RV (31.3% vs. 7.5%, p = 0.008). After adjustment for clinical characteristics, patients with RV volume index >120 ml/m2 were at almost a 5 times higher risk for 1-year mortality compared to patients with smaller RV (HR 4.9, 95% CI 1.8-13.1, p = 0.002). The addition of echocardiographic parameters to the propensity score did not eliminate the significance of RV volume index >120 ml/m2 as an independent predictor for mortality at 1-year. An analysis of RV as a continuous variable demonstrated that the risk for 1-year mortality increased by 2% for every 1 ml/m2 RV volume enlargement (p = 0.013). Conclusions Cardiac volumetric data by CCTA performed for procedural planning may help predict outcome in patients undergoing TAVR. Abstract P1423 Figure. Cox survival curves according to RVi

Aims The prevalence and prognostic implications of left atrial appendage (LAA) thrombus (LAAT) in patients considered for transcatheter aortic valve replacement (TAVR) are incompletely defined. We, therefore, studied pre-procedural cardiac computed tomography angiography (CCTA) scans of TAVR candidates to determine the prevalence of LAAT and its association with late outcomes. Methods and results Baseline clinical variables and CCTA findings from a prospective TAVR registry were analysed for the prevalence of pre-procedural LAAT and its impact on in-hospital outcomes and late mortality. LAAT was differentiated from LAA filling defects (LAAFD) reflecting stasis without clot. Patients (n = 561) with complete in-hospital and late mortality data were included in the study (median follow-up 31.6 months). LAAT and LAAFD were evidenced on pre-procedural CCTA in 24 (4.3%) and 26 (4.6%) patients, respectively. One hundred fourteen (20.3%) patients died during the study period. Though in-hospital adverse event rates (including stroke) did not differ among groups, mortality at long-term follow-up was higher among LAAT patients compared with those with or without LAAFD (58.3% vs. 11.5% vs. 19.0%, respectively; P Conclusions LAAT visualized by pre-procedural CCTA is an independent predictor of late mortality following TAVR, but not peri-procedural stroke. When reporting TAVR-CCTA, particular note should be made of LAA features and presence of LAAT which may have prognostic and management implications.

Background Acute kidney injury (AKI) complicating transcatheter aortic valve implantation (TAVI) is relatively frequent and associated with significant morbidity. Previous studies have shown a higher 30-day and 1-year mortality risk in patients with periprocedural AKI. Our aim was to identify the prognostic impact of periprocedural AKI on long-term follow-up. Methods This is a single-center prospective study evaluating patients undergoing TAVI for severe aortic stenosis. AKI was defined according to the Valve Academic Research Consortium 2 definition, as an absolute increase in serum creatinine ≥0.3 mg/dL or an increase >50% within the first week following TAVI. Mortality data were compared between patients who developed AKI and those who did not. Logistic and Cox regressions were used for survival analysis. Results The final analysis included 1086 consecutive TAVI patients. AKI occurred in 201 patients (18.5%). During the follow-up period, 289 patients died. AKI was associated with an increased risk of 30-day mortality {4.5 versus 1.9% in the non-AKI group; hazard ratio [HR] 3.70 [95% confidence interval (CI) 1.35–10.13]}. Although 1-year mortality was higher in the AKI group in univariate analysis, it was not significant after a multivariate regression. AKI was a strong predictor of longer-term mortality [42.3 versus 22.7% for 7-year mortality; HR 1.71 (95% CI 1.30–2.25)]. In 189 of 201 patients we had data regarding recovery from AKI up to 30 days after discharge. In patients with recovery from AKI, the mortality rate was lower (38.2 versus 56.6% in the nonrecovery group; P = 0.022). Conclusions Periprocedural AKI following TAVI is a strong risk factor for short-term as well as long-term mortality (up to 7 years). Therefore more effort is needed to reduce this complication.

Objectives This study sought to evaluate mechanisms of effort intolerance in patients with rheumatic mitral stenosis (MS). Background Combined stress echocardiography and cardiopulmonary testing allows assessment of cardiac function, hemodynamics, and oxygen extraction (A–Vo2 difference). Methods Using semirecumbent bicycle exercise, 20 patients with rheumatic MS (valve area 1.36 ± 0.4 cm2) were compared to 20 control subjects at 4 pre-defined activity stages (rest, unloaded, anaerobic threshold, and peak). Various echocardiographic parameters (left ventricular volumes, ejection fraction, stroke volume, mitral valve gradient, mitral valve area, tissue s′ and e′) and ventilatory parameters (peak oxygen consumption [Vo2] and A–Vo2 difference) were measured during 8 to 12 min of graded exercise. Results Comparing patients with MS to control subjects, significant differences (both between groups and for group by time interaction) were seen in multiple parameters (heart rate, stroke volume, end-diastolic volume, ejection fraction, s′, e′, Vo2, and tidal volume). Exercise responses were all attenuated compared to control subjects. Comparing patients with MS and poor exercise tolerance ( Conclusions In patients with rheumatic MS, exercise intolerance is predominantly the result of restrictive lung function, chronotropic incompetence, limited stroke volume reserve, and peripheral factors, and not simply impaired valvular function. Combined stress echocardiography and cardiopulmonary testing can be helpful in determining mechanisms of exercise intolerance in patients with MS.

To evaluate the effect of baseline aortic valve gradient (AVG) both as a continuous and a categorical variable on mortality in patients undergoing transcatheter aortic valve replacement (TAVR), focusing on the high-gradient severe aortic stenosis (AS) patients.Identifying new predictors of mortality in the TAVR population can help refine risk stratification and improve the patient selection process for this procedure. So far, AVG has mainly been studied as a categorical variable and there is a paucity of data on its prognostic value as a continuous variable, especially in patients with high AVG AS, who constitute the majority of patients referred for TAVR.We analyzed data on 1,224 consecutive symptomatic severe AS patients, who underwent TAVR at 3 centers. The relation between pre-TAVR AVG and mortality was evaluated among all patients and in patients with high AVGs (mean AVG ≥40 mm Hg) using the Cox proportional hazard model adjusting for multiple variables.During a mean follow-up of 1.8 years, baseline AVG was inversely associated with mortality in the entire cohort and in patients with high AVG AS. By multivariable analysis, patients with mean AVG 40-60 mm Hg and60 mm Hg had a respective 38% (P = 0.010) and 61% (P 0.001) reduction in mortality compared to patients with mean AVG40 mm Hg. Every 10 mm Hg increase in mean AVG was associated with 20% reduction in mortality (P 0.001). Analyses among patients with high (mean AVG40 mm Hg) and very high AVG AS (mean AVG60 mm Hg) yielded similar results (HR = 0.88, P = 0.031, and HR = 0.80, P = 0.019, per 10 mm Hg increase in AVG, respectively). Using peak AVGs and an analysis restricted to patients without reduced ejection fraction yielded consistent results.Baseline AVGs show an inverse association with mortality post-TAVR. These results were consistent also in patients with high-gradient AS, suggesting that AVG can be used to identify patients most likely to benefit from TAVR.

Balloon pre-dilatation before transcatheter aortic valve replacement (TAVR) is performed at the discretion of the treating physician. Clinical data assessing the implications of this step on procedural outcomes are limited.We conducted a retrospective analysis of 1164 consecutive TAVR patients in the Israeli multicenter TAVR registry (Sheba, Rabin, and Tel Aviv Medical Centers) between the years 2008 and 2014. Patients were divided to those who underwent balloon pre-dilation (n=1026) versus those who did not (n=138).Rates of balloon pre-dilation decreased from 95% in 2008-2011 to 59% in 2014 (p for trend=0.002). Baseline characteristics between groups were similar except for more smoking (22% vs. 8%, p=0.008), less past CABG (18% vs. 26%, p=0.016), less diabetes mellitus (35% vs. 45%, p=0.01), and lower STS mortality scores (5.2±3.7 vs. 6.1±3.5, p=0.006) in the pre-dilatation group. The pre-dilation group included less patients with moderate to severely depressed LVEF (7% vs. 16%, p0.001) and higher aortic peak gradients (76.9±22.7mmHg vs. 71.4±24.3mmHg, p=0.01). Stroke rates were comparable in both groups (2.5% vs. 3%, p=0.8), but pre-dilation was associated with lower rates of balloon post-dilatation (9% vs. 26%, p0.001). On multivariate analysis, balloon pre-dilatation was not a predictor of device success or any post-procedural complications (p=0.07).Balloon pre-dilatation was not associated with procedural adverse events and may decrease the need for balloon post-dilatation. The results of the present study support the current practice to perform liberally balloon pre-dilatation prior to valve implantation.

Background Discriminating circulatory problems with reduced stroke volume (SV) from deconditioning, in which the muscles cannot consume oxygen normally, by gas exchange parameters is difficult. Methods We performed combined stress echocardiography (SE) and cardiopulmonary exercise tests (CPET) in 110 patients (20 with normal effort capacity, 54 with attenuated SV response, and 36 with deconditioning) to evaluate multiple hemodynamic parameters and oxygen content difference (A- V . o 2 Diff) in four predefined activity levels to assess which of the gas measures may help in the discrimination. Results Reduced anaerobic threshold (AT), low unchanging peak oxygen pulse, periodic breathing, shallow Δ peak oxygen consumption ( V . o 2 )/Δwork rate (WR) ratio, and high expired volume per unit time/carbon dioxide production ( V . e / V . co 2 ) slope were all associated with abnormal SV response ( P V . e / V . co 2 slope to V . o 2 ratio (≥ 2.7; area under the curve [AUC], 0.79; P V . o 2 /ΔWR V . e / V . co 2 slope to peak V . o 2 ratio ≥ 2.7, and periodic breathing (AUC of 0.84; P Conclusions The best single gas exchange parameter to discriminate between circulatory problems and deconditioning is V . e / V . co 2 slope to peak V . O 2 ratio. Combining it with Δ V . o 2 /ΔWR and periodic breathing improves the discriminative ability.

Combining echocardiography and cardiopulmonary stress testing allows noninvasive assessment of hemodynamics, and oxygen extraction (A-VO 2 difference). We evaluated mechanisms of effort intolerance in patients with heart failure with borderline (40% to 49%) left ventricular ejection fraction (EF) (HF and Borderline Ejection fraction). We included 89 consecutive patients with HF and Borderline Ejection fraction (n = 25; 63.6 ± 14 years, 64% men), control subjects (n = 22), patients with HF with preserved EF (n = 26; EF ≥50%), and patients with HF with reduced EF (n = 16; 2 ] and A-VO 2 difference) were measured at 4 predefined activity stages. Effort-induced functional MR was frequent and more prevalent in HF and Borderline Ejection fraction than in all the other types of HF. In multivariable analysis heart rate response (p 2 difference (p = 0.02), stroke volume (p = 0.002), and right ventricle end-systolic area were the only independent predictors of exercise capacity in HF and Borderline Ejection fraction but peak EF was not. In HF and Borderline Ejection fraction exercise intolerance is predominantly due to chronotropic incompetence, peripheral factors, and limited stroke volume reserve, which are related to right ventricle dysfunction and functional MR but not to left ventricular ejection fraction. Combined testing can be helpful in determining mechanisms of exercise intolerance in HF and Borderline Ejection fraction.

Background Radiologists and cardiologists have a remarkably different approach to the clinical importance and to the need for prophylactic treatment of contrast-induced acute kidney injury (CI-AKI). Objectives To evaluate the efficacy of forced diuresis with matched controlled hydration (FMH) in a real-world, high risk population. Methods This is an investigator-driven, single-center, retrospective analysis of prospectively collected data. A total of 150 consecutive patients undergoing coronary angiography, angioplasty or TAVR who were treated with FMH were compared to a matched historical control cohort. Results In the FMH treated patients, eGFR improved following the procedure from 37ml/min per 1.73m 2 at baseline to 39ml/min per 1.73m 2 ( p p 2 to 33.2ml/min per 1.73m 2 post procedurally ( p p p Conclusions In patients undergoing coronary angiography, angioplasty or TAVR, who are considered high risk to develop post procedural AKI, forced diuresis with matched controlled hydration resulted in a significant net creatinine decrease, eGFR increase and a decrease in the incidence of AKI.

Background Transcatheter aortic valve replacement (TAVR) is an alternative to open cardiac surgery in selected patients with severe aortic stenosis (AS). Carotid artery stenosis (CAS) has been associated with an increased risk of stroke following cardiac surgery, although the association between CAS and outcomes following TAVR is unclear. We therefore sought to study the prognostic impact of CAS on outcomes of patients undergoing TAVR. Methods Consecutive patients (n=312) with severe symptomatic AS who underwent a carotid Doppler study immediately prior to TAVR were followed prospectively. Major adverse cardiovascular event (MACE) rates were stratified by the presence of CAS, defined in accordance with current practice guidelines. Results Carotid atherosclerosis (CA, defined as any carotid plaque) was present in 301 (96.5%) of patients and CAS (peak systolic velocity [PSV]≥125cm/s; ≥50% diameter stenosis) in 97 (31.1%) patients. Severe CAS (PSV≥230cm/s; ≥70% stenosis, or near occlusion) was found in 20 (6.4%) patients. At long-term follow-up (248±205days), composite (20.9% vs. 19.6%, p=0.50) and individual (all-cause mortality, stroke, myocardial infarction, readmission for heart failure [19.5%% vs. 14.4%%, p=0.24; 3.3% vs. 2.1%, p=0.47; 1.4% vs. 0%, p=0.22; and 7.9% vs. 8.2%, p=0.84 respectively]) MACE rates did not differ significantly between patients without versus those with CAS. By multivariate analysis, CAS was not independently predictive of late MACE rates (HR=0.85, [95%CI 0.50–1.78], p=0.85). Conclusions CAS was not associated with worse outcomes following TAVR. The relative prognostic significance of CAS in patients considered for either surgical or transcatheter valve replacement merits further research.

Background Risk stratification in patients undergoing transcatheter aortic valve replacement (TAVR) is limited and based on clinical judgment and surgical AVR scoring systems. Recently, extent of cardiac damage using an echocardiographic classification was purposed to assess prognosis of patients undergoing TAVR. We aimed to validate this new scoring system in a real-world cohort and to examine the addition of baseline albumin in risk assessment. Methods We investigated 2,608 patients undergoing TAVR. All subjects had an echocardiography test prior to TAVR. Subjects were divided into five groups based on their echocardiography findings: stage 0 – 758 (29%) patients, stage 1 – 769 (30%), stage 2 – 730 (28%), stage 3 – 320 (12%) and stage 4 (1.2%). Patients were further assessed by incorporating baseline albumin. Results Mean age of study population was 82±7 years. Kaplan-Meier's survival analysis showed that the cumulative probability of mortality was significantly higher among subjects with increased stage compared to the lower stages (p KM according to stage and albumin Conclusions Cardiac damage classification is validated in a real-world cohort of patients undergoing TAVR. Incorporation of low baseline albumin may further identify patients at the highest risk group.

The aim of this study was to assess the prognostic implications of increased right ventricle volume index (RVVI) using cardiac-gated computed tomography angiography (CCTA) data among patients undergoing transcatheter valve replacement (TAVR).CCTA of 323 patients who underwent TAVR at Stanford University Medical Center (CA, USA) and Tel Aviv Medical Center (Israel) between 2013 and 2016 was analysed by an automatic four-chamber volumetric software and grouped into quartiles according to RVVI. Higher one-year mortality rates were noted for the upper quartiles - 5%, 4.9%, 8.6%, and 16% (p=0.039), in Q159 ml/m2, Q2 59-69 ml/m2, Q3 69-86 ml/m2, and Q486 ml/m2, respectively. However, the differences were not significant after propensity score adjustments. Sub-analyses of Q1 demonstrated an escalating risk for one-year mortality in concordance to RVVI: HR 2.28, HR 2.76, and HR 4.7, for the upper 25th, 15th, and 5th percentiles, respectively (p0.05 for all comparisons). After propensity score adjustments for clinical and echocardiographic characteristics, only the upper 5th percentiles (RVVI120 ml/m2) retained statistical significance (HR 2.82, 95% CI: 1.02-7.78, p=0.045). Notably, 68.7% of patients from this group were considered low-intermediate risk for surgery.Cardiac volumetric data by CCTA performed for procedural planning may help to predict outcome in patients undergoing TAVR.

Aims Acute kidney injury (AKI) is a common complication following transcatheter aortic valve implantation (TAVI) and is associated with increased risk for short- and long-term mortality. In patients undergoing percutaneous coronary intervention (PCI), forced diuresis with matched hydration has been shown to reduce the incidence of AKI by ∼50%. The aim of the present study was to evaluate whether forced diuresis with matched intravenous hydration reduces AKI in patients undergoing TAVI. Methods and results Reducing Acute Kidney Injury (REDUCE-AKI) was a single-centre, prospective, randomized, double-blind sham-controlled clinical trial, designed to examine the effect of an automated matched saline infusion with urine output for the prevention of AKI in patients undergoing TAVI. A total of 136 TAVI patients were randomized, 68 in each group. Mean age was 83.9 ± 5 years and 41.2% were males. There were no differences in baseline characteristics between the two groups. The rate of AKI was not statistically different between the groups (25% in the active group vs. 19.1% in the sham group, P = 0.408). There was a significant increase in long-term mortality in the active group (27.9% vs. 13. 2% HR 3.744, 95% CI 1.51–9.28; P = 0.004). The study was terminated prematurely by the Data Safety Monitoring Board for futility and a possible signal of harm. Conclusions Unlike in PCI, forced diuresis with matched hydration does not prevent AKI in patients undergoing TAVI, and might be associated with increased long-term mortality. Future studies should focus on understanding the mechanisms behind these findings. Clinicaltrials.gov registration NCT01866800, 30 April 2013.

Background:Polymorphic ventricular tachycardia (VT) without QT prolongation is well described in patients without structural heart disease (mainly idiopathic ventricular fibrillation and Brugada syndrome) and in patients with acute ST-elevation myocardial infarction.Methods:Retrospective study of patients with polymorphic VT related to coronary artery disease, but without evidence of acute myocardial ischemia.Results:The authors identified 43 patients in whom polymorphic VT developed within days of an otherwise uncomplicated myocardial infarction or coronary revascularization procedure. The polymorphic VT events were invariably triggered by extrasystoles with short (364±36 ms) coupling interval. Arrhythmic storms (4–16 events of polymorphic VT deteriorating to ventricular fibrillation) occurred in 23 (53%) patients. These arrhythmic storms were always refractory to conventional antiarrhythmic therapy, including intravenous amiodarone, but invariably responded to quinidine therapy. In-hospital mortality was 17% for patients with arrhythmic storm. Patients treated with quinidine invariably survived to hospital discharge. During long-term follow-up (of 5.6±6 years; range, 1 month to 18 years), 3 (16%) of patients discharged without quinidine developed recurrent polymorphic VT. There were no recurrent arrhythmias during quinidine therapyConclusions:Arrhythmic storm with recurrent polymorphic VT in patients with coronary disease responds to quinidine therapy when other antiarrhythmic drugs (including intravenous amiodarone) fail.

Increased inflammatory response after aortic valve replacement is linked to higher postprocedural mortality. The aim of the present analysis was to assess the impact of baseline statin therapy on procedural outcomes and mortality after transcatheter aortic valve implantation (TAVI). We performed a retrospective analysis on patients who underwent TAVI stratified to 3 statin therapy groups: high-intensity statin (HIS), low-medium intensity statins, and no statin. Included were 1,238 patients. Patients treated with HIS were significantly younger, had higher body mass index, lower Society of Thoracic Surgeons score, and higher prevalence of dyslipidemia, hypertension, past stroke, and ischemic heart disease. Procedural outcomes were similar between groups. There were no statistically significant short-term mortality differences at 1 month (2.2% vs 2.1% vs 3.5%, p = 0.50) and 1 year (6.9% vs 9.3% vs 14.2%, p = 0.15), albeit the observed numerical trend. As for long-term mortality (median follow time of 2.5 years, interquartile range 1.3 to 4.2), lower mortality rates were observed in the HIS group (14.5% vs 25.2% vs 36.6%, p = 0.001). Compared with no statin, the HIS group was significantly associated with reduced risk of long-term mortality in multivariate analysis (hazard ratio = 0.59, 95% CI 0.37 to 0.96, p = 0.03). Baseline HIS therapy is associated with reduced rates of long-term morality after TAVI.

OBJECTIVE To compare procedural outcomes of transcatheter aortic valve implantation (TAVI) patients who were implanted with older versus newer generation valves. BACKGROUND The current evidence base for improved safety of the newer commercially available TAVI valves is limited. METHODS A retrospective analysis of the Israeli multicenter TAVI registry was performed. Patients were stratified by valve generation of four commercially available devices: Edwards Sapien (ESX) Edwards Sapien S3 (ES3), Medtronic CoreValve (MCV), and Medtronic Evolut R (MER). RESULTS The cohort consisted of 737 patients with new generation valves (NGVs; ES3 n = 223; MER n = 514) and 1,869 with old generation valves (OGVs; MCV n = 1,181; ESX n = 688). Device success rates were significantly higher in NGV (97.5 versus 95.4%), with less post-procedural paravalvular leak (3 versus 5.8%), and valve mal-positioning (1.2 versus 3.4%); all P-values

Background About a decade past the first transcatheter aortic valve implantation (TAVI), data are limited regarding temporal trends accompanying its evolution from novel technology to mainstream therapy. We evaluated these trends in a large multicenter TAVI registry. Hypothesis TAVI is changing and improving with time. Methods Patients who underwent TAVI between January 2008 and December 2014 at 3 high-volume Israeli centers were divided into 5 time quintiles according to procedure date. Outcomes were analyzed and reported according to Valve Academic Research Consortium-2. Results A total of 1285 patients were studied (43% male; mean age, 83 ± 3 years; mean Society of Thoracic Surgeons [STS] score, 5.5 ± 3.6). Over time, there was a shift toward treating patients at lower STS score, increased use of conscious sedation and transfemoral approach, and decreased use of balloon predilatation. The balloon-expandable to self-expandable valve utilization ratio decreased, the valve-in-valve experience increased from 4% to 17% of all TAVI volume, and length of hospital stay was halved (P = 0.006). Kaplan-Meier survival curves showed gradual decrease in mortality risk (P = 0.031), but there was no significant 1-year mortality decrease by multivariable analysis. Each year increment was associated with an adjusted 20%, 15%, and 12% decrease in new pacemaker obligation (P = 0.004), new pacemaker obligation or left bundle branch block (P = 0.008), and in-hospital infections (P = 0.082), respectively. Conclusions Temporal trends accompanying TAVI evolution include its utilization in lower-risk patients, procedural simplification, improved overall survival, decreased pacemaker obligation, and shorter hospital stay.

Direct mechanical compression of the frame struts on the adjacent bundle branch with local inflammatory reaction might cause conduction system disturbances and need for pacemaker implantation following transcatheter aortic valve implantation (TAVI). We assessed the impact of preprocedural anti-inflammatory steroid therapy on the occurrence of conduction disturbances following TAVI.From a cohort of 324 patients who underwent transfemoral TAVI, 39 (12%) were pretreated with steroids because of iodine allergy (n=29) or active obstructive pulmonary disease (n=10). We compared the rate of occurrence of new conduction disturbances and pacemaker implantation between TAVI patients with (n=39) and without (n=285) steroid treatment, using Cox logistic regression estimates and proportional hazards models. The overall occurrence of new conduction defects and the need for new pacemaker implantation were similar among steroid and non-steroid-treated patients (38.4% vs 37.5% and 25.6% vs 25.3%, respectively). New conduction disturbances were more prevalent in patients treated with CoreValve prosthesis, low implantation, and smaller aortic annulus diameter (P

OBJECTIVES High values of Red Blood Cell Distribution Width (RDW) have been associated with adverse outcome in various clinical settings. The mechanism behind this association is not clear. The Metabolic Syndrome (MetS) is a chronic inflammatory disorder that increases the risk for cardiovascular disease and death. The aim of our study was to evaluate the association between high RDW and the MetS in a relatively large cohort of patients. METHODS A cohort of 3,529 consecutive patients undergoing coronary angiography was used to evaluate the association between RDW and the MetS. The association was assessed by using a logistic regression. Cox's regression analysis was used to evaluate the impact of RDW on long term mortality. RESULTS The mean age was 65 years (range 24-97), with 27% women. Overall, 30% were diagnosed with metabolic syndrome. The prevalence of MetS was 29% in patients with RDW

Background The efficacy and safety of thrombectomy as an adjunct to primary percutaneous intervention (PCI) in the management of acute myocardial infarction (AMI) are debated. We performed a meta-analysis of randomized trials comparing primary PCI performed with versus without routine aspiration thrombectomy (AT). Methods A meta-analysis of randomized AT trials reporting clinical outcomes was done in accordance with the PRISMA guidelines. Trials reporting only non-clinical endpoints and those of technologies other than manual devices were excluded. The primary endpoint of this meta-analysis was mortality (either all-cause or cardiovascular). Secondary endpoints were reinfarction, stent thrombosis, and stroke. Results Seventeen randomized trials, involving 20,853 patients were included. Weighted mean follow-up was 9.3±3.3months. The rates of all-cause mortality (reported in 14 trials, n=10,430) and cardiovascular mortality (reported in 6 trials, n=11,810) did not differ significantly between patients treated with or without AT (4.6% vs. 5.3%, RR=0.88 [95%CI=0.75–1.04]; and, 3.0% vs. 3.7%, RR=0.83 [95%CI=0.68–1.01]; respectively). The rates of reinfarction and stent thrombosis were also similar in patients treated with versus those treated without AT (2.1% vs. 2.2%; RR=0.96 [95%CI=0.80–1.15]; and, 1.2% vs. 1.4%; RR=0.84 [95%CI=0.65–1.07], respectively). However, stroke rates were increased with AT (0.84% vs. 0.52%, RR=1.56 [95%CI=1.09–2.25]). Conclusions Routine AT as an adjunct to primary PCI does not reduce the rates of death, reinfarction, or stent thrombosis, but is associated with increased stroke risk.

Objectives: Previous studies investigating the prognostic value of HbA1c in patients undergoing coronary angiography reported a mixed pattern of results. Therefore, we aimed to better define the prognostic power of HbA1c among coronary catheterized patients. Methods: Patients undergoing coronary angiography (n = 3,749) were divided into four groups according to HbA1c levels (7%). Cox regression models assessed long-term mortality after adjusting for multiple covariates. Results: Baseline clinical profiles differed in HbA1c groups, with a higher prevalence of comorbidities in the groups with higher HbA1c levels. Median follow-up was 1,745 days (interquartile range 1,007-2,171). A J-shaped association curve was observed between HbA1c levels and all-cause mortality rates, with patients in the lowest and highest HbA1c groups suffering from significantly higher mortality rates compared to in-between groups (hazard ratio 1.9, 95% CI 1.32-2.74, p = 0.001, and hazard ratio 1.58, 95% CI 1.29-1.95, p < 0.001, for the lowest and highest HbA1c groups, respectively). This association persisted after adjustment for anemia, nutritional status, renal function, cardiovascular risk factors and inflammatory biomarkers. Conclusions: HbA1c levels 7% are predictors of all-cause mortality in patients undergoing coronary angiography.

We evaluated temporal trends in gender-related differences in patients who underwent transcatheter aortic valve implantation (TAVI) for severe symptomatic aortic stenosis from a multicenter TAVI registry during the years 2008 to 2016. Our final cohort included 1,159 males and 1,370 females, with a median follow-up of 2.3 (IQR 1.2, 4.4) years. For temporal trends analysis, the entire population was divided according to period of procedure: 2008 to 2012 and 2013 to 2016. During the 2008 to 2012 period, the rates of in-hospital aortic paravalvular leak, myocardial infarction, pacemaker implantation, and stroke were higher among men than women, but became comparable between the gender during the 2013 to 2016 period. Multivariate analysis demonstrated that female patients who underwent TAVI between the years 2008 and 2012 had a 26% lower risk of death compared with male patients (p = 0.004), but there were no gender-related differences in mortality risk between the years 2013 and 2016 (hazard ratio 1.07, p = 0.6; gender-by-year of procedure, p = 0.027 for interaction). In conclusion, the favorable long-term prognosis described in female patients during the earlier TAVI period seemed to diminish with contemporary TAVI. This might be attributed to current technological advances and improved valve sizing, with a more significant benefit in favor of male patients.

To compare procedural outcomes of transcatheter aortic valve replacement (TAVR) patients treated with new-generation valves. We performed a retrospective analysis on an Israeli multicenter registry comprised of four tertiary centers, comparing patient outcomes implanted with the Edwards SAPIEN S3 (ES3) vs. the Medtronic Evolut R (MER) valves. The study population included 735 patients (ES3 n = 223; MER n = 512). The use of MER was significantly associated (p

Objectives To investigate the impact of preprocedural left ventricular (LV) diastolic function on outcomes of patients with postprocedural aortic regurgitation (ARpost) following transcatheter aortic valve replacement (TAVR). Background The predictors and mechanisms of the increased mortality in patients with ARpost are inadequately defined. Methods Baseline clinical and echocardiographic variables from a prospective TAVR registry were analyzed. Preprocedural correlates of late outcomes (all-cause mortality and the composite of mortality, stroke, heart failure, and new-onset atrial fibrillation) were examined according to the presence and severity of ARpost. Results Of the 418 patients undergoing TAVR, ARpost was present in 212 (51%): mild 36%, moderate–severe 15%. Mean follow-up was 909 ± 489 days. All-cause mortality and composite endpoint rates were significantly increased in patients with moderate–severe ARpost compared with patients with either none or only mild ARpost (38, 22, 21%, P = 0.02; and, 56, 35, 40%, P = 0.01; respectively). Moderate–severe (though not mild) ARpost was independently associated with mortality and the composite endpoint (HR = 1.93 [95%CI 1.15–3.14], P = 0.01; HR = 1.85 [95%CI 1.22–2.77], P = 0.004], respectively). By multivariate analysis, preprocedural LV deceleration time (DT)

Objectives The purpose of this study was to assess individual mechanisms of effort intolerance in patients with heart failure with preserved ejection fraction (HFpEF), heart failure with reduced ejection fraction (HFrEF), or normal cardiac function using combined echocardiography and cardiopulmonary stress testing. Background Combined stress echocardiography and cardiopulmonary tests visualize cardiac chambers in 4 well-defined activity levels (rest, unloaded, anaerobic threshold, and peak), allowing noninvasive assessment of cardiac function, hemodynamics, and arterial venous oxygen content difference (A Vo 2Diff) during all stages. Methods Left ventricular volumes, stroke volume (SV), S', E/e', oxygen consumption (Vo 2), and A Vo 2Diff were measured in all effort stages using ramp semirecumbent cycle prolonged (≥8 min) exercise in 45 consecutive subjects evaluated for effort intolerance (14 normal cardiac function, 16 HFpEF, and 15 HFrEF patients; age 56.5 ± 16 years; 73% male). Results In HFpEF and HFrEF, the changes in Vo 2 were attenuated (between group p = 0.003; group by time interaction p Vo 2Diff (p Conclusions Combined tests are feasible and allow noninvasive evaluation of effort intolerance. In HFpEF and HFrEF patients, exercise intolerance is predominantly due to chronotropic incompetence and peripheral factors. Combined stress echocardiography and cardiopulmonary tests may have potential for clinical management and selection of patients for trials.

AIMS Anemia and inflammation are both associated with unfavorable outcomes in patients with ischemic heart disease and might be pathophysiologically linked. We aimed to analyze the additive value of anemia and inflammation on the outcomes of patients undergoing percutaneous coronary intervention. METHODS Cox regression models were fitted for hemoglobin and C-reactive protein (CRP) cut-offs and performed separately for myocardial infarction (MI) and angina pectoris patients undergoing catheterization at a tertiary hospital between 2006 and 2011. Major adverse cardiovascular events (MACEs) were defined as all-cause mortality, MI and stroke. RESULTS Included were 1976 patients (825 with angina pectoris and 1151 with MI). The median follow-up in the MI and the angina pectoris groups was 14 and 13 months, respectively (maximal follow-up of 4 years). In the MI group, the risk of MACE during follow-up was increased with the presence of either anemia (hazard ratio 2.1, P = 0.07) or of elevated CRP (hazard ratio 1.9, P = 0.04), whereas the presence of both increased the risk even further (hazard ratio 3.4, P

Background Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is frequent and is associated with adverse outcomes. Past studies have attributed AKI to impaired kidney function at baseline, amount of contrast medium used, major bleeding, and hemodynamic instability during the procedure. Because major bleeding might play a role in the development of AKI, we analyzed the relationship between periprocedural bleeding and the development of AKI and assessed the impact of these 2 important procedure-related complications on outcome. Methods Consecutive patients undergoing transfemoral TAVI for severe aortic stenosis were prospectively recruited. AKI and bleeding events during hospitalization were recorded, defined, and classified according to the Valve Academic Research Consortium 2 definitions. Logistic and Cox regression was used for predictor and survival analyses. Results We recruited 422 consecutive patients who underwent TAVI; the mean follow-up duration was 576 ± 400 days. AKI occurred in 66 (15.6%) patients. No patient required dialysis. Fifty patients (12%) had major or life-threatening bleeding. Periprocedural major or life-threatening bleeding was a strong predictor of the development of AKI (odds ratio, 3.19; 95% confidence interval [CI], 1.38-7.1; P = 0.006). Major bleeding was a strong independent predictor for both 30-day and long-term mortality (hazard ratio [HR], 6.67; 95% CI, 2.2-19.8; P = 0.001 and HR, 3.3, 95% CI, 1.2-9.0; P = 0.02, respectively), whereas AKI was not independently associated with increased mortality after TAVI. Conclusions In patients undergoing transfemoral TAVI, periprocedural bleeding is a strong risk factor for the development of AKI and a major determinant of short- and long-term mortality.

Vascular complications (VC) after transcatheter aortic valve implantation (TAVI) are reported using various criteria and several access site approaches. We aimed to describe them in a solely percutaneous transfemoral TAVI approach and their association with survival using both the updated Valve Academic Research Consortium (VARC)-2 criteria and the former VARC-1 criteria. From March 2009 to September 2013, 403 consecutive patients at a mean age (±SD) of 83 ± 6 years underwent percutaneous transfemoral TAVI. VC were defined by both VARC-1 and VARC-2 criteria and analyzed separately. Cox proportional hazard ratio models for all-cause mortality were adjusted separately as defined by each criteria. VARC-1-defined and VARC-2-defined VC occurred in 71 (18%) and 78 (19%) patients, respectively, with 15 (4%) and 33 (8%) defined as major VC. The difference in frequency of major and minor VC was mainly driven by VARC-2 implementation of major bleeding events. With either VARC definition, patients with minor VC had similar mortality and complications rates as those patients without VC. In multivariate analyses, referenced to patients with minor or no VC, only VARC-1-defined major VC were significantly associated with increased mortality (hazard ratio 3.52; confidence interval 1.5 to 8.4; p = 0.005), whereas VARC-2-defined major VC were found to be only marginally significant (hazard ratio 1.9; confidence interval 0.9 to 3.9; p = 0.08). In conclusion, the implementation of the VARC-2 criteria resulted in a higher rate of reported major VC after TAVI compared with VARC-1 criteria, mainly by the inclusion of major bleeding events and a reduced association with patient mortality.

Background— The magnitude of QT prolongation in response to bradycardia, rather than the bradycardia per se, determines the risk for torsade de pointes during atrioventricular block (AVB). However, we do not know why some patients develop more QT prolongation than others, despite similar bradycardia. We hypothesized that in patients who develop significant QRS vector changes during AVB, the effects of cardiac memory lead to excessive QT prolongation. Methods and Results— We studied 91 patients who presented with AVB and who also had an ECG predating the bradyarrhythmia for comparison. We correlated changes in QRS morphology and axis taking place during AVB with the bradycardia-induced QT prolongation. Patients with and without QRS morphology changes at the time of AVB were of similar age and sex. Moreover, despite similar R-R interval during AVB, cases with a QRS morphology change had significantly longer QT (648±84 versus 561±84; P Conclusions— Cardiac memory resulting from a change in QRS morphology during AVB is independently associated with QT prolongation and may be arrhythmogenic during AVB.

High RDW values are associated with adverse prognosis in many clinical conditions including short and medium term outcome of patients with ST Elevation Myocardial Infarction (STEMI). The aim of the present study was to evaluate the association between RDW and long term mortality in STEMI patients undergoing primary angioplasty (PPCI).A cohort of 535 STEMI patients undergoing PPCI were divided into two groups (RDW14%, RDW ≤ 14%) using CHAID and CART methods. The association between RDW and 5-year all-cause mortality was assessed using Cox's proportional hazards analysis.A total of 37 patients died during follow up of 5 years (mean: 1059, median: 1013, range 2-2130 days). RDW14% was associated with increased risk of all-cause mortality (HR = 5, CI 95% 2.7- 9.9, p0.001). In multivariate analysis, RDW14 remained significantly associated with increased risk for all-cause mortality (HR = 3.8, CI 95% 1.8- 7.99, p0.001). Patients with RDW above 14% did not have lower ejection fraction, higher CPK or more conventional risk factors.RDW value above 14 is independently associated with increased long term all-cause mortality in patients with STEMI undergoing PPCI.

Background Neutrophil/lymphocyte ratio (NLR) is a novel biomarker that can single out individuals at risk for vascular events. We assessed whether NLR provides additive prognostic value in patients with ST-elevation myocardial infarction (STEMI). Methods NLR was computed from the absolute values of neutrophils and lymphocytes from the complete blood count of patients who underwent primary coronary angioplasty for STEMI. The cohort was divided into 2 groups according to NLR (NLR ≥ 6.5%, NLR 2 automatic interaction detection. The association between NLR and in-hospital clinical complications and left ventricular ejection fraction (EF) was assessed using logistic regression. The association between NLR, 30-day and 5-year all-cause mortality were analyzed using Cox regression models, adjusting for potential clinical, metabolic, and inflammatory confounders. Results In a group of 538 consecutive STEMI patients, high NLR (NLR ≥ 6.5%) was independently associated with increased 30-day and 5-years mortality rates (odds ratio, 15.8; 95% confidence interval, 1.6-154; P = 0.018; and hazard ratio, 2.2; 95% confidence interval, 1.04-4.8; P = 0.039, respectively). High NLR was also independently associated with lower EF (49 ± 8 vs 46 ± 8; P Conclusions In patients presenting with STEMI, high NLR was independently associated with lower EF, fewer hospital complications, and higher mortality rates up to 5 years. NLR value appears additive to conventional risk factors and commonly used biomarkers.

Background Two important causes of sudden death during endurance races are arrhythmic death and heat stroke. However, “arrhythmic death” has caught practically all the attention of the medical community whereas the importance of heat stroke is less appreciated. Objectives The study sought to determine what percentage of life-threatening events during endurance races are due to heat stroke or cardiac causes. Methods This retrospective study examined all the long distance popular races that took place in Tel Aviv from March 2007 to November 2013. The number of athletes at risk was known. The number of athletes developing serious sport-related events and requiring hospitalization was known. Life-threatening events were those requiring mechanical ventilation and hospitalization in intensive care units. Results Overall, 137,580 runners participated in long distance races during the study period. There were only 2 serious cardiac events (1 myocardial infarction and 1 hypotensive supraventricular tachyarrhythmia), neither of which were fatal or life threatening. In contrast, there were 21 serious cases of heat stroke, including 2 that were fatal and 12 that were life threatening. One of the heat stroke fatalities presented with cardiac arrest without previous warning. Conclusions In our cohort of athletes participating in endurance sports, for every serious cardiac adverse event, there were 10 serious events related to heat stroke. One of the heat stroke–related fatalities presented with unheralded cardiac arrest. Our results put in a different perspective the ongoing debate about the role of pre-participation electrocardiographic screening for the prevention of sudden death in athletes.

Objectives Our aim was to analyze the prevalence and predictors of Carotid artery stenosis (CAS) in patients undergoing transcatheter aortic valve implantation (TAVI). Background CAS is associated with the risk of periprocedural stroke in patients undergoing cardiac surgery. However, little is known about the prevalence of and clinical significance of CAS in the setting of TAVI. Methods Consecutive patients undergoing a carotid Doppler study the day before TAVI were followed prospectively. CAS was defined in accordance with current practice guidelines. Logistic regression models were used to identify independent correlates of CAS. Results The study included 171 patients (age 82 ± 6, male gender 47%). Carotid atherosclerosis (CA, defined as any carotid plaque) was present in 164 (96%) of patients, and CAS (peak systolic velocity [PSV] ≥ 125 cm/sec; ≥50% diameter stenosis) in 57 (33%) patients. Severe CAS (PSV ≥ 230 cm/sec; ≥70% stenosis, or near occlusion) was found in 15 (9%) patients. By multivariate analysis, smoking and a higher Euroscore independently predicted the presence of CAS. Patients in the present TAVI cohort had a significantly higher prevalence of both unilateral and bilateral CAS ≥ 50% than those in a previously reported cohort (n = 494 patients, age ≥ 70) undergoing clinically driven coronary angiography (33% vs. 20%, OR = 1.9, P = 0.001; and, 13% vs. 6%, OR = 2.3, P = 0.003, respectively). CAS was not independently associated with 30-day mortality or stroke rates. Conclusions The prevalence of CAS in patients undergoing TAVI is high, exceeding that observed in patients undergoing catheterization for coronary indications. The impact of CAS on clinical outcomes following TAVI merits further research. © 2014 Wiley Periodicals, Inc.

Background An increased serum glucose level in patients with acute coronary syndrome (ACS) is associated with adverse clinical outcome. This hyperglycemia has been attributed, at least in part, to acute stress reaction. Our objective was to determine whether hyperglycemia is a stress-related phenomenon or whether it represents a more sustained and possibly significant background dysglycemia. Hypothesis Hyperglycemia in patients undergoing coronary angiography is related to background dysglycemia. Methods Blood samples were obtained at the time of cardiac catheterization. Patients with hemoglobin A1c >6.5% were excluded to avoid patients with chronic glucose levels above 135 mg/dL. A logistic regression model was created to assess the influence of different variables on hyperglycemia (glucose levels above 140 mg/dL). We also evaluated the effect of glucose levels above 140 mg/dL on major adverse cardiovascular events (MACEs) up to 36 months. Results There were 2554 consecutive patients prospectively recruited. Serum glucose levels above 140 mg/dL was a strong predictor of MACE (hazard ratio: 2.2, 95% confidence interval [CI]: 1.3-3.6, P = 0.002). Both diabetes mellitus and ACS were associated with hyperglycemia (glucose levels above 140 mg/dL). Nevertheless, the incidence of hyperglycemia was doubled in diabetic patients (odds ratio [OR]: 9.4, 95% CI: 3.9-22.4, P < 0.001) compared with patients with ACS (OR: 4.6, 95% CI: 2.3-9.0, P < 0.001). Combining both conditions was associated with a high likelihood of elevated glucose levels (OR: 15.5, 95% CI: 7.4-32.9, P < 0.001). Conclusions Hyperglycemia in patients undergoing cardiac catheterization is a strong predictor of adverse outcome. It is mainly related to background dysglycemia and to a lesser extent to the acute stress accompanying ACS.

Background During radiofrequency (RF) ablation of paroxysmal atrial fibrillation, a circular multielectrode recording "lasso" catheter is generally positioned within each pulmonary vein (PV) to determine when pulmonary vein potentials (PVPs) are present and when they have been ablated. The new irrigated multipolar nMARQ circular ablation catheter is positioned within the left atrium to create contiguous circular ablation lines around each PV ostium. Objective To determine whether the recordings obtained from the nMARQ catheter position around the PV ostium accurately reproduce the recordings obtained from a lasso catheter positioned within that vein. Methods In 10 patients undergoing RF ablation of paroxysmal atrial fibrillation, we placed an nMARQ and a lasso catheter around and within each PV, respectively. Recordings obtained from both catheters at baseline and after RF ablation were compared. Results At baseline, recordings of PVPs in both catheters were concordant in 92% of all PVs. However, after RF delivery, the concordance between the nMARQ and lasso recordings was poor. The discordant result most commonly observed was disappearance of "PVPs" from the nMARQ catheter with persistence of PVPs in the lasso catheter (12 of 39 [30%]). Conversely, the delivery of RF frequently resulted in fragmented electrograms (pseudo-PVPs) on the nMARQ catheter despite evidence of PV isolation by lasso catheter recordings. Conclusions The use of an nMARQ catheter alone, as currently recommended, may lead to underestimation and overestimation of the number of RF applications required to achieve PV isolation.

BACKGROUND The phenomenon of slow coronary flow (SCF) in the presence of normal coronary arteries may indicate endothelial dysfunction, which is characteristic of an early stage in the development of atherosclerosis. Measurement of the Carotid Intima-Media Thickness (CIMT) allows identification of early stages of atherosclerosis. CIMT might offer a non-invasive method of diagnosing SCF patients. Previous studies demonstrated conflicting results regarding the relationship between these two phenomena. In the present study, we examined the association between coronary flow velocity and the degree of CIMT in patients with angiographically normal coronary arteries. METHODS Coronary arterial blood flow velocity was measured using two methods - Corrected Thrombolysis in Myocardial Infarction (TIMI) Frame Count (CTFC) and Coronary Clearance Frame Count (CCFC). In addition, we measured the level of the CIMT using a special automated computerized software. RESULTS Seventy Five consecutive patients were prospectively recruited. No correlation was found between CIMT and mean CTFC (r = -0.08, p = NS) or mean CCFC (r = -0.07, p = NS). In addition, CIMT values did not differ between the SCF and the Normal coronary flow (NCF) groups (0.796 mm vs. 0.805 mm, respectively, p = 0.733). Patients with SCF had higher levels of hematocrit (39.9% vs. 36.1%, p < 0.001), LDL cholesterol (101.1 mg/dl vs. 85.8 mg/dl, p = 0.01) and higher rate of current smokers (28.9% vs. 10.8%, p = 0.05). CONCLUSIONS Patients with angiographically normal coronary arteries and SCF do not have increased CIMT values. However, current smoking, higher LDL cholesterol and hematocrit levels are all related to slower coronary blood flow.

The impact of age on baseline characteristics and outcomes in patients with severe aortic stenosis who undergo transcatheter aortic valve implantation (TAVI) has not been thoroughly investigated. To describe the baseline clinical profile of TAVI patients aged >85 and ≤85 years and to evaluate the influence of age differences on outcomes, we evaluated a consecutive cohort of 293 patients who underwent transfemoral TAVI at the Tel Aviv Medical Center. The cohort was divided into 2 groups: patients aged >85 years (n = 93) and patients aged ≤85 years (n = 200). Mean age was 83 ± 5.3 years (range 63 to 98) for the entire cohort. Women comprised 70% of the older group and 57.5% of the younger age group (p = 0.043). Baseline clinical profile, including EuroSCORE index and preprocedural aortic valve area were similar in both age groups. Thirty-day mortality, major vascular complications, need for permanent pacemaker implantation, length of hospital stay, and improvement in functional class after the procedure showed no differences between the 2 groups. Adjustment for baseline clinical differences between groups did not change the results. In conclusion, among patients who underwent transfemoral TAVI, older patients (>85 years) experience similar benefits and outcomes regarding functional status, complication rates, and 30-day mortality.